Interscalene brachial plexus nerve block in the emergency department: an effective and practice-changing workshop

Abstract

Background The interscalene brachial plexus nerve block (ISNB) is a potentially useful method of regional analgesia for humerus fracture and shoulder dislocation reduction in the Emergency Department (ED). We examined the effectiveness of an ISNB workshop given to emergency medicine (EM) residents. We also explored complication rates and effectiveness of ISNBs performed in the ED. Methods One-hour evidence-based ISNB workshops were conducted with EM residents. Participants were given pre-, post-, and 3-month post-workshop knowledge and technical assessments. Results were analyzed using descriptive statistics. A pre- and post-workshop chart review examined ISNB utilization, complications, post-ISNB opiate administration, and post-ISNB procedural sedation. Results 41 residents enrolled in the workshop. Pre-workshop pass rate: knowledge assessment 22%. Immediate post-workshop pass rates: knowledge assessment 100%, image acquisition 93%, needle placement 100%. Three months post-workshop pass rates: knowledge assessment 73%, image acquisition 76%, needle placement 100%. Areas of poorest knowledge retention were anatomical landmarks, block distribution, and early signs of LAST. In the chart review, 2 ISNBs were performed in the pre-workshop period, and 12 in the post-workshop period. No serious complications were recorded. 78.5% of attempted ISNBs were successful, without need for procedural sedation. Of the 11 successfully performed ISNBs, 91% received no opiates after the procedure. Conclusions Our study suggests that EM residents can learn the ISNB, perform it safely in the emergency department, and that the ISNB may be an alternative to procedural sedation and opiate use for shoulder dislocation. Residents are adept at ISNB technical skills but demonstrate some deficits in knowledge retention.

Success rate of anterior shoulder dislocation reduction by emergency physicians: a retrospective cohort study

“…It was not reported if this was because they were old and at high risk for drugs use or because of ED overcrowding. A previous study showed that landmark‐guided shoulder joint injections were misplaced in 41.1% of cases by EPs [ 18 ]; the success rate of the interscalene brachial plexus nerve block by EPs was 71% [ 19 ]; shoulder dislocation reduction required a moderate depth of sedation [ 20 ]. Our study did not record pain score and sedation depth, although the 15 patients who used sedatives or analgesics may have had inadequate pain relief or sedation.…”

Regional Anesthesia in the Emergency Department: an Overview of Common Nerve Block Techniques and Recent Literature

“…There are multiple studies examining various methods of teaching UGRA to EPs [36,[75][76][77]. Beals et al conducted a feasibility study to assess if IBPBs could be effectively taught to EM residents through a 1-h workshop [36].…”

“…There are multiple studies examining various methods of teaching UGRA to EPs [36,[75][76][77]. Beals et al conducted a feasibility study to assess if IBPBs could be effectively taught to EM residents through a 1-h workshop [36]. Postworkshop, 93% of participants passed an image acquisition assessment, and 100% passed needle placement assessments, with pass rates 3 months post-workshop being 76% and 100%, respectively [36].…”

“…Beals et al conducted a feasibility study to assess if IBPBs could be effectively taught to EM residents through a 1-h workshop [36]. Postworkshop, 93% of participants passed an image acquisition assessment, and 100% passed needle placement assessments, with pass rates 3 months post-workshop being 76% and 100%, respectively [36]. Retrospective chart review at the authors' institution found that only 2 IBPBs performed pre-workshop and 12 performed post-workshop [36].…”

“…Of the three, the suprascapular nerve block is the easiest and safest to perform but most limited in area of distribution. The interscalene and supraclavicular blocks, although highly effective for multiple types of injuries, require injecting close to major vascular structures and carry some risk of causing temporary diaphragmatic paralysis [15,36]. The supraclavicular block is performed in the region of the apex of the lung and thus carries risk of accidental pneumothorax, although when performed with UG, the risk is minimal [4 •, 11].…”